cheryl taylor, rpn positive wellness north island services new treatment and mental health issues

CHERYL TAYLOR, RPN

POSITIVE WELLNESS NORTH ISLAND SERVICES

New Treatment and Mental Health Issues

HCV and Mental Health Issues

A European Consensus Statement on HCV infection, antiviraltreatment and Mental Health was published in The Journal of Hepatology, Dec. 2012. (43 recommendations)

The paper summarizes current knowledge of HCV and the brain; prevalence, course,and neurobiology of IFN associated psychiatric side effects; possible risk factorsfor INF associated depression and suicide attempts, psychiatric management of HCV patients before, during and AFTER antiviral treatment; prevention of IFN associated side effects and psychiatric aspects of new antivirals.


Psychiatric co-morbidity is significantly more prevalent in patients with chronic HCV infection than in the general population.

Emerging evidence suggests that mental health problems may be associated with the infection itself, possibly mediated by an effect on the CNS

Mental health problems during antiviral treatment may reduce treatment compliance and are risk factors for treatment failure.

Schaefer et Al, Hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec 2012.


Overall, depression during IFN-α treatment develops in 30–70% of the treated patients.

Fatigue represents probably the most prominent neuropsychiatric side effect as it develops in up to 80% of the patients.

Sleep alterations, irritability, anxiety, and cognitive disturbances may occur in up to 50% of the patients.

Mania, and psychosis represent more rare adverse events of IFN-α treatment- up to 3% of pts.

Suicidal ideation up to 10%-attempts or completion reports remain anecdotal


New Medications and Mental Health Issues

Currently available data show that both new antivirals do not have specific neuropsychiatric side effects.

Telaprevir- the most common “psychiatric” adverse events are fatigue and insomnia, depression was only evaluated in one trial with an incidence of 20-22% in all groups.

Boceprevir- no additional psychiatric side effectsAntipsychotic treatment- olanzepine is

recommended based on the low rate of interactions.



The treatment of psychiatric side effects may be complicated by possible drug-drug interactions.

Benzodiazepines such as midazolam, alprazolam (Xanax) and triazolam(Halcion) should NOT be combined with the new antivirals due to increased blood levels and sedative effects.

Escitalopram (Cipralex) showed a lowered blood concentration of around 35% with Telaprevir.



Antipsychotic treatment- olanzepine is recommended based on the low rate of interactions.

Up to date information about possible drug-drug interactions should be considered for in the management of tx induced psychiatric side effects.

Many possible drug-drug interactions with hypnotics, antidepressants, antipsychotic, methadone, and antiepeleptics and more specific data are required.

Schaefer et Al, hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec 2012.


Timing is important ! Multiple overlay of symptoms early on in treatment make it more difficult to identifying psychiatric symptoms.

Consensus conference suggests that : a) 10-14% of patients discontinue therapy due to

a psychiatric adverse event such as fatigue, depression, irritability or insomnia.

b) Only approximately one third of pts. who develop depression on tx are correctly diagnosed.

Schaefer et Al, hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec 2012.

Case Study

Kate – 54 yrs. Stage II FibrosisHx of psoriasis and Psoriatic ArthritisOn disability pension due to chronic painPartner heavy drinker, hx of violence in homeClient very private.BDI score 8 indicating no current depressive

symptoms. Intermittent trouble with anxiety, taking clonazepan 0.5mg prn. Psychiatric Hx as teenager.

No sleep disruptionHigh level of “unrealistic optimism” about tx. 1

Hopwood et al. “Experiences of HCV Treatment and it’s Management”, Ntl. Centre of HIV Research, 2006

Case Study

Safety plan made with Kate should she need to leave her home during tx

Started attending clinic Tx support groupStarted tx Nov 7/12Hg fell quickly, VERY fatigued, loss of appetiteIn first few weeks flare of her arthirits. Concerns

re: med interactions, rheumatologist consult, no med changes made. Week 3 sleep disruption. Imovane initiated wk 4

Case Study

Week 8, rash and flare up of psoriasis, query Incivik rash

Week 1o BDI score 13, indication of mild depressive symptoms, client reports being teary, anxious, and overwhelmed- sent to GP who was reluctant to start Celexa, started on suboptimal dose 10 mg, good effect in one week

(f/u letter sent to GP with tx guidelines)Week 12 Kate presents with another rash. She

thinks it started shortly after starting Celexa-on view clinic RN queries Ribavirin rash

Case Study

Clinic Gastroenterologist d/c Celexa and initiates Trazadone with urgent referral to skin specialist.

5 days on Trazadone, depressive symptoms increase, client not coping well, feeling “drugged in am”, having panic attacks, using clonazepam daily, Requested she discuss Celexa with specialist at next day appointment . (Remains DETERMINED!)

At appointment, specialist decided to biopsy, client so overwhelmed she forgets to ask about Celexa

Case Study

Contacted specialist re: Celexa . GP calls client to re-initiate Celexa, as specialist did NOT think it was a Celexa rash- continue to query Ribavirin rash????

Client reinitiated Celexa, stopped TrazadoneWeek 12 PCR- Continue to monitor and client continues to

attend Tx support group.

Timing of Side Effects

Differentiating physical side effects and psychiatric issues challenging complex due to timing of presentation.

Differential Time difference for neurovegetative/somatic symptoms vs. mood/cognitive symptoms.

Neurovegetative and somatic symptoms i.e. fatigue, decreased appetite, pain, GI disorders, develop early, usually in first weeks of tx

Schaefer M. et al. Hepatitis C. Antiviral Treatment and Mental Health: A European Expert Consensus Statement. Journal of Hepatology, 2012.


Mood and cognitive symptoms including depression, anhedonia, memory disturbances,

and concentration usually develop after Week 4, with the greater intensity of

depressive symptoms between Weeks 8 - 16


Most neuropsychiatric side effects (hypomania, mania, psychoses) appear between weeks 10 and 24 and may persist until tx completion, then resolve with treatment cessation

Cases of persistent, recurring or new developing symptoms have been described

Schaefer et Al, Hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec 2012


WHY IS TIMING SO IMPORTANT?

1-4 wks 4-16 wks 16-48 weeks


Standard therapy:Peginterferon and Ribavirin

Add one of two protease inhibitors: Te l a p r e v i r

B o c e p r i v i r

Neuro-vegetative Sx start immediately

Mood/Cognitive Sx start Week 4, peak Week 8, con’t through Tx

N e u r o p s y c h i a t r i c s y m p t o m s

or

MOOD AND COGNITIVE SYMPTOMS•Difficulty concentrating, remembering details, and making decisions•Fatigue and decreased energy•Persistent aches or pains, headaches, cramps, or GI problems that don’t ease w. Tx cessation •Overeating or appetite loss•Insomnia, early-morning wakefulness, or excessive sleeping•Irritability, restlessness•Feelings of guilt, worthlessness, and/or helplessness•Feelings of hopelessness and/or pessimism•Loss of interest in activities or hobbies once pleasurable, including sex •Persistent sad, anxious, or "empty" feelings•Thoughts of suicide (up to 10% of patients)• Suicide attempts (case reports, anecdotal) NEURO-VEGETATIVE/ SOMATIC

SYMPTOMS•Fatigue•Decreased appetite•Pain•GI Issues

NEUROPSYCHIATRIC SYMPTOMS

HypomaniaMania Rare Adverse EventsPsychoses 3%

Not assessing for risk factors puts patients at RISK

Risk factors for depression on tx:Depression during previous IFN TxDepressive symptoms pre-TxSleep disturbances pre-TxEarly vegetative symptoms (sleep disruption, loss

of appetite) Baseline stress and lack of social support

Schaefer et Al, Hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec 2012

IMPLICATIONS FOR PRACTICE

MANAGEMENT OF ACUTE DEPRESSION AND

PREVENTION

Symptoms are highly responsive to serotonergic antidepressants

Agent selection needs to consider drug-drug interaction and underlying hepatic toxicity

First line antidepressant is Celexa (not above 40 mg)

Second line antidepressants include Cipralex, Paxil, Zoloft and Remeron and other SSRI’s

Continue for 12 weeks after Tx cessationEarly Tx of sleep disturbancesSchaefer et Al, Hep. C infections and antiviral treatment and mental health. J. of Hepatology, Dec

2012.

MANAGEMENT OF ACUTE DEPRESSION AND

PREVENTION

Prophylactic Tx with antidepressants in clients with previous Hx of IFN-based depression

HCV clients with symptoms of depression at baseline should receive antidepressants pre-treatment-proper assessment is critical.

Antidepressant therapy is so far NOT generally recommended for all HCV clients during antiviral therapy and should be based on a case by case decision.


CONSENSUS STATEMENT

A concomitant and continuous psychotherapeutic support program has recently been shown to be able to reduce acute psychiatric complications and the need for pharmacological interventions during antiviral therapy.1

Strategies to improve psychological adjustment to chronic medical illness increase social support, social stigmatization, promote lifestyle changes (alcohol use, nutrition, exercise, work) and give information about possible side effects of antiviral therapy all significantly improve treatment adherance.2

Lends support for standardized psychiatric pre-tx assessment and pre-tx planning .

1,2,Schaefer M. et al. Hepatitis C. antiviral treatment and mental Health : A European expert Consensus Statement. Journal of Hepatology 2012.

Take Away

2/3 of your clients on tx may be experiencing undiagnosed depression – implications for tx

discontinuation and compliance.

Take Away

Mood Assessment Tools are the “bloodwork” of psychiatry. Pre/during and post tx mood assessment at structured intervals using

validated tools + sleep assessment are now considered best practice

QUESTIONS?

Contact

Cheryl Taylor, RPNMental Health and Addictions Services941-C England AvenueCourtenay, BCEmail: [email protected] Phone:250-331-8524

Resources:Hepatitis C infection, antiviral treatment and Mental Health : A European

Expert Consensus Statement-Schaefer M. et al. Journal of Hepatology, 2012.

PHQ-9 - http://www.deanbrown.ca/forms/MHA/PHQ9.pdf

“Experiences of Hepatitis C Treatment and its Management: What some patients and health professionals say.” Hopwood, et Al, National Centre in HIV Social Research Faculty of Arts and Social Sciences, University of New South Wales

cheryl taylor, rpn positive wellness north island services new treatment and mental health issues

Documents

mental health issueshcv

mental health issuesoverall

ifn treatment

treatment failure

treatment compliance

cnsmental health problems

psychiatric aspects

new medications